315 LAFAYETTE ST - BUILDING INSPECTION ` r
\ 02N The Commonwealth of Massachusetts
Department of Public Safety
Ulf Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied. -Budding Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whi arlable)
315 1i4 -✓d YC l 9,AL GW4 0 �O
No.and Street City/Town Zip Code ame adding(if ap li
SECTION 2:PROPOSED WORK --
Edition of MA State Code used z If New Construction check here❑or check all that app y in the-two rows below
Existing Building❑ Repair Y I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ NoXl
Brief Description of Proposed Work:
� d r,4An i e Rue'
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY '
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)8r Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ " -'- R: Residential R-10 R-2❑ R-3 OY R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ ILIA ❑ 11113 ❑ IV ❑ 1 VA O VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
� Trench Permit: Debris Removal:
Water Suppyq: Flood Zone Information: Sewage Disposal: Licensed Disposal Site
Public Check if outside Flood Zone Indicate municipal A trench ill not be P
required or trench or specify:
Private❑ or indcntify Zone or on site system❑ permit is enclosed❑
Railroad right-of-w y: Hazards to Air Navigation: IIA I Ii toriCunnm,sion Rovii w i Process:
Not Applicable Is Structure within airport a proach area? Is their review co leted?
or Consent to Build enclosed❑ Yes❑ or No Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and dd ess of Property Owner
,at,*A ( -' or- ,If- ac g ,4k- s Aeg
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
C�c.4 A 1 part.fie I�—Q V Z31 - c�(33
Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the proppt�r ow er hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed spice and or.not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.22 General Contractor
Company Name
Name of Person Responsible for Construction License No. anti Type if Applicable
R 6C,4(-c i�L*� A(&<a V�6,,L I*Lq _C6--
SStttr�eet/A�d/dresss�J��j City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:t40f'KF,IZS'COAIPFN,-A"CIO\ INSUItAt�C F AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ O Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (FIVAC) $ Note:Minimum fee=$ (contact our ipality�
5.Mechanical Other $ Enclose check able to
6.Total Cost $ payable
7 lYyV (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereM^__
rider the pains and penalties of perjury that all of the information contained it this
application is true and ace rate to tmy knowledge and understanding.
��fr 0 , 1 11 &0� v"92 791 -�Cff33
Please pri an sign(a7 / /fitly" Telepho a
G
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name - Date
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 7911 -
SCOTT A THIBODEAU
8 STEARNS ST
SWAMPSCOTT; MA 01907
Expiration: 9/10/2013 '
('ununissiunrr Tdt: 4705
CITY OF SALEINfa NL1Ss,1CHusE-Frs
a SUILDING DEP.1R' L&NT
l'_O WASHNGTON STREET, 31O FLOOR
CSaea» ,. TEL (978) 745-9595
Rai:(973) 1•10-9844
;UJIDEp-LEY DRISCOLL THo.%LuST.Pmtxs
MAYOR DIRECTOR OF PUBLIC PROPE11TY/0C)LONG CO-NLNIISS(ONEEt
Workers' Cumpensatlon insurance AfITdavit: Builders/Contractorq/Electr(cians/Plumbers
Ailllilcant Infitrmatlnn /I Please Print Legibly
Muni:(Ousinesr L
.Organizaiiomindividual): . 6 Ro i� alit Gv. l r.t.L
Address: 8 o04 Ks
City/Statcalp: L h04 019K Phone#: 7V 63 ( w33
Are an ampioyer?Cheek the appropriate boss 'type of project(required):
I. i am a employer with_ _ ❑ (Am a general contractor and 1 6. ❑Now construction
employees((III and/or part-lime).• have hired the sub-contractors
2.Q I am a sole proprietor or partner, listed on the attached sheet t 1. ❑Remodeling
.chip and have no employees These sub-contractors have N. Q Demolition
Working fur me in any capacity. workers'comp.Insurance. 9, Q Building addition
(No workers'camp.insurance S. Q Wears a corporation and its
required.) aMccrs have exercised their 10.Q Electrical repairs or additions
3.0 I am a homeowner doing all wark right of exemption per MGL 11.Q Plumbing repairs or additions
myself.(\'a workers'comp. c. 152,91(4),and we have no 12. y�alvFn airs
insurance required.)r employees.LNo workers' ram/ P2a.nS
comp.insurances mqulmd.l 15. Other 1
;Any applicunr aul chucks Iws Alios l Meant alas ail Out the octim below showing chair waken'compensation policy inlltrmotlon.
'I hvnvuwdrr who tulmtil this stlidavit indicating they am doing all work and tbca him outside eomraetore midi auhntfl a now amdavil indicting "IL
C�tntraenn that chuck this box must Outled an addhlurwl+hsl showing the name of the rubvvntrrctan and their wurkere'comp,pulley infarmaeon.
l con on eatp/uyer that providing Ivorkers'cantpensardon huuranee for my employeest Below/at rbe pollry and Job rile
injonrrurlon. _
ImumuceCuntpany?lmme; SSGC.. xt:74',4L Cca�
Policy 4 or Sclf•ins. Lie, 0: V WC, 6417'7 lG 126 /—L . apiretion Date: + /4 13
Job Sita Addruss:_ / Lie �if � City/State/Zip:_ S(.aU,
.1ltacb a Copy of the+vorkers'compensa loo pulley declaration page(Ihowing the policy number and expiration data).
F`allure to sccuru covomgo as required under Scetion 25A of&IGL c. 152 can lead to the imposition of criminal penalties of s
line up to S1,500.00 undlur one-year imprisonment,as well as civil punaltios in(he form of a STOP WORK ORDER and a line
of up to 52S0.00 a day against ilia violator. Ile advised that a copy of this statemunt may be forwarded to the Oflicd of
Mvcsligwiuta ui t DIA fur insurance coverages vcrilicaliun.
1,10 lrereby err rhd paint uuJ pmm/det ujpar/ury that the GrfonnuNou pravlJad buv is true and curled
Phone,l: t
r)/Jreru!use wJ)t Ou out write in r/r/t are,4 to be cumplemal by city ur town n/Jlelut !
I
City nr fown: ._ _ Purmlt/i.lccnre:9
Issuluq,luthurily (circle tine):
1. iluard of i(eallh Z. Iluilding i)eparhnenl I.Cily/fowo Clerk 1. Electrical (nrpeetor i. Pluulbinq Iuapector
5.Other
Contact I'ertmr _ ... . .. Phone;):
I
;. CITY 0,F'S,U ENf, itiLkSS:ICHUSETTS
BUILDING DEP.1IML&rT
120 VV.kjjqc4GTO,%j STREET, 3w FLOOR
TEL (978) 145-9595
F.LY(978) 7.10-93M
U\[DE4L.EY D(ZISCO[l.
P.L�Yolt T IOMAS ST.PIER"
DIRECTOR OF PULIC PROPERTY/8LM0LYG CONNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation Work)
In accordance with the sixth edition of the State Building Coda, 730 CbfR section 1 l 1.5
Debris, and the provisions of tbfGL c d0, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by NfGL c
111, S I50A.
The debris will be transported by:
11lanle ufhauler)
The debris will be disposed of in :
(nanlc of tactlity)
se � S �
(�ddres.c of fa;ility)
- si�namrc ufpermit applicant
I